Triage, teamwork lessons learned from earthquakes, tsunamis and terrorist attacks

Within minutes or days of a mass trauma event, hundreds — possibly thousands — of patients may arrive at the emergency room of a hospital nearest the site of the incident. At these times, orthopaedic surgeons can play a key role in the triage and treatment of patients. Later, when these patients undergo limb salvage, reconstruction or amputation procedures, these physicians typically perform the surgery or are involved in the ongoing management of patients.

Orthopaedics Today Europe spoke with orthopaedic surgeons who have been in these situations, including war, tsunamis, earthquakes and terrorist attacks. They said it is nearly impossible to fully prepare to receive these kinds of patients, but having some kind of plan, even a rough one, for their management — before a mass trauma disaster occurs — can be helpful.

“If an orthopaedic surgeon decides to work in a conflict area, he has to be well-trained and experienced, with a sound knowledge of vascular and general surgery,” Roberto Fedeli, MD, told Orthopaedics Today Europe. “It would be useful to include in the training curriculum the presentation of specific conflict-related surgical cases, the treatment, the environment and the facilities available where the treatment was carried out.”

Learning takes place onsite

Marko Bumbasirevic, MD, PhD, who was born in and lives in Belgrade, Serbia, has long-standing experience in the treatment of patients with high-energy injuries and is trained in microvascular surgery. He discussed what was involved in the treatment of the large number of patients injured as a result of the NATO bombing of then Yugoslavia, modern-day Serbia, which began on March 24, 1999.

“I was not in the first arriving unit at the scene of the incident, but the patients were coming in large numbers to the hospital and our civilian hospital. Many of the departments were converted to military departments,” Bumbasirevic said. “We have a military academy, but they could not treat such a large number of patients.”

Most of the injuries he saw were blast injuries from bombs and missiles. In soldiers, 70% of the injuries involved the limbs because the helmets and armor they wore had a protective effect. The civilians’ injuries were more severe, he said.

Experience with high-energy injuries helpful

At the outset of what he calls the “ex-war,” Bumbasirevic and colleagues did not have much experience in the treatment of these kinds of patients.

“Quickly we learned how to treat these patients,” he said.

The surgeons often had to rely on their previous experience treating patients with other types of high-energy injuries, such as from automobile crashes.

“I would say the same protocol was used for these patients,” many of whom had severe open fractures, Bumbasirevic said.

Communication, triage

Communication is important in these situations, he noted.

“At the scene, the triage is probably the most important thing — how to judge which patients were the most emergency cases,” but that is not always easy. It is particularly challenging for onsite personnel who are not trained to triage patients in this type of situation, Bumbasirevic said.

“Sometimes, it is important to get the patient as soon as possible to the hospital. I do not say that is definitive treatment, but I would say what we call now damage control orthopaedics is of prime importance,” Bumbasirevic said.

On-hand after natural disasters

Orthopaedic surgeons may feel less prepared when natural disasters, like tsunamis and earthquakes, strike.

Banchong Mahaisavariya, MD, PhD, and colleagues treated people injured when a tsunami hit Thailand on Dec. 26, 2004. They wrote in the Journal of Orthopaedic Surgery about how facilities, such as Takuapa Hospital of Phang Nga province, were severely affected by the large number of patients who presented with injuries after the huge waves hit the beaches and damaged areas inland.

Most of the injuries these tsunami victims sustained were to the lower limb because they were submerged underwater. According to the authors, most of the patients who died did so from drowning, being trapped in buildings that collapsed or being thrown under cars.

Help when help is needed

Within the first 3 hours of the tsunami, more than 1,000 patients presented to the emergency room and 500 patients were admitted, although Takuapa Hospital was only capable of handling about 60 patients in a mass trauma situation. At the time, there were 10 physicians, including two orthopaedists and one surgeon, on-hand at the hospital. The word that more help was needed was spread by the ambulance drivers since the telephone service was out. The hospital had four operating theaters.

“Most patients were unable to be operated on within the golden period. Almost all wounds were treated late and gradually became infected,” Mahaisavariya and colleagues wrote.

Earthquake recovery is challenging work

Fedeli a general surgery specialist trained in orthopaedic surgery, participated in a rescue team after the 2004 tsunami in the Indian Ocean that affected Sri Lanka.

“In my experience, after a tsunami, local and neighboring health services can deal with all the medical emergencies. There are few activities for an orthopaedic surgeon,” he told Orthopaedics Today Europe.

Fedeli, who is a technical advisor to the Italian Cooperation, Ministry of Foreign Affairs and International Cooperation, also participated in recovery efforts following the earthquake in Haiti on Jan. 12 2010, that killed 222,570 people and affected 3.5 million people in the developing nation. He said organizations outside Haiti arrived within 18 hours of the earthquake to help.

“It took some time to start health activities on a large scale. The discrepancy between the needs and the resources available during the first 2 weeks was responsible for the magnitude of human losses. This was confirmed by a study conducted by the University of Michigan. At least 20% of the victims died within 6 weeks after the disaster from medical complications due to delay in treatment,” Fedeli said.

Rely on outside agencies, experts

Private hospitals and international organizations already on site in Haiti provided the initial medical aid.

“All these institutions were not sufficiently prepared to handle a large number of casualties,” Fedeli said.

However, due to what Fedeli called an “unprecedented” international response to the earthquake, a key lesson was learned regarding what it takes to be effective after a disaster in a country with minimal infrastructure.

“It is necessary for intervening agencies to have experience in this type of country. The medical teams should have a capacity not limited to medical matters, but also in logistic, administrative and financial matters,” he said.

Infected wounds most problematic

Fedeli said data on injuries sustained from the Haiti earthquake were incomplete because various groups reported them in different languages and used an array of classification systems. The incidence of upper and lower limb fractures was about 22% and amputation rates were 0.5% to 16%, with infected wounds making up most medical problems (18% to 60%), he noted.

“The exact number of amputations is unknown, but well over 1,500,” he said.

These were required because of a delayed intervention, insufficient postoperative care and a lack of external fixators.

“In this context, guillotine amputations were widely used,” Fedeli said.

This resulted in many patients who needed more subsequent treatment than usual, so they could be fitted with prostheses.

Damage control orthopaedics

Twice, Thierry Bégué, MD, was involved in mass casualty situations in Paris. The most recent was the terrorist attack in November 2015. The other after a bomb attack on the streets of Paris in 1986, when he was a resident. He said it is hard for orthopaedic surgeons to learn or be prepared for what to do in settings that require them to focus on and treat multiple patients simultaneously.

“A lot of it will be done in the field,” he told Orthopaedics Today Europe.

However, according to Bégué, “We have to train a lot of surgeons, not only the residents, the younger ones, but also the senior ones, about damage control in mass casualty attacks.”

The message of that training, he said, should be to not waste time trying to save a patient’s limb when the patient is multiply injured or when other patients await the surgical team’s attention and expertise.

Attacks in Paris

In November 2015, Bégué was not involved immediately after the attack, but as an expert in the reconstruction of damaged limbs, he received 12 patients in his department 3 days after the attack in the second phase of treatment.

“I was in close relationship with all the different departments to manage the patients, not in the early phase, but as a reference center,” said Bégué, who learned the importance of triage in the 1986 bombing.

It was advantageous, he said, that both of these attacks in Paris occurred during the daytime or early evening when many physicians and nurses were still at work in nearby hospitals. This helped with management and for quickly establishing teams of one physician or resident and one nurse each to address the many patients who arrived at the emergency department (ED) of the nearest hospital.

Medical coordinator in place

During the November attack, patients were rapidly assessed and transferred to other area hospitals so only one or two severely injured patients were at each hospital inside that district of Paris; a process orchestrated by someone who acted as a medical coordinator and was in contact with ambulances and hospitals.

Severely injured patients were dispatched from street-level directly to various hospitals by ambulance or helicopter. This created a situation in which the hospital closest to where the trauma occurred typically ended up with the bulk of the least severely injured patients.

“It was exactly what I saw in 1986. We received a severe one at the early phase, only one patient. After that, we saw a lot of different people coming to the ED on their own or with their friends or people surrounding the level of the attack,” Bégué said. “Nowadays, we maintain a system in France that the nearest hospital is completely away from the severe ones because we know that a lot of patients will come on their own directly to this hospital.”

Save life, not limb

Bégué shared other lessons learned from being involved in these two incidents. He urged orthopaedic surgeons to accept that they will not be able to save every part of every patient’s limb or every limb. For example, he decided to go directly to amputation for three of the 12 patients he treated in November 2015 because the reconstruction would be too difficult. Furthermore, the function of the operated limb would also be minimal.

“If it is only a unique injury, we will try to maintain it as much as possible,” he noted.

Reconstruction is typically delayed until the second or third day after the injury and is proceeded by repeated debridement to remove the dead tissue.

“Infection must be guarded against,” Bégué said.

“Depending on the amount or size of the bone gap, external fixation should be used first because its stability tends to be better,” Bégué said.

Circular frames are a good choice for comminuted fractures.

“In fact, the stability is better when you are able to use internal fixation as soon as possible,” Bégué said.

Flap coverage, filling the gap

After fixation, flap coverage techniques are used. The options for osteosynthesis or bone-void filling include spacers, and sometimes stem cell implants and bone marrow treatment, Bégué said. At the time of reconstruction, surgeons must be convinced the limb is reconstructable, be sure there is sufficient nerve function and keep in mind that limb function will be worse when the injury occurred close to a joint.

“It is important for the orthopaedic surgeon to explain that early on to the patient, that they will likely never regain or recover normal joint function,” Bégué said.

He said the senior surgeon — whomever has the most experience — should have these discussions with severely injured patients and recommended that person be the head of the department.

In terms of their prognosis, patients should only be given a general overview of what might transpire with treatment, as well as a global timetable for recovery.

“The chief of orthopaedics is the chief of the orchestra. The [chief] use other teams, but lead[s],” Bégué said.

In these situations, he has worked closest with plastic surgeons, but has interfaced with the rehabilitation center, amputee organizations and the prosthetic department at his hospital.

Bégué wants mass casualty training to be included in the orthopaedic and traumatology training curriculum, ideally during bullet trauma sessions at international trauma meetings. – by Susan M. Rapp

• References:
• Bumbasirevic M, et al. Int Orthop. 2012.doi:10.1007/s00264-012-1638-y.
• Bumbasirevic M, et al. J Am Acad Orthop Surg. 2006;14:S77-81.
• Kolbe AR, et al. Med Confl Surviv. 2010;doi:10.1080/13623699.2010.535279.
• Watcharong C, et al. J Orthop Surg (Hong Kong). 2005; 13:1-2.

• For more information:
• Thierry Bégué, MD, can be reached at Hôpital Antoine Béclère, Université Paris-Sud, 157, rue de la porte de Trivaux, 92140 Clamart, France; email: thierry.begue@aphp.fr.
• Marko Bumbasirevic, MD, PhD, can be reached at Univerzitet u Belgrade, Medicinski fakultet Dr Subotia 8, 11 000 Belgrade, Serbia; email: marko.bumbasirevic@gmail.com.
• Roberto Fedeli, MD, can be reached at via Azzurra 58, 40100 Bologna, Italy; email: fedelir@yahoo.it.
• Banchong Mahaisavariya, MD, PhD, can be reached at Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand; email: banchong.mah@mahidol.ac.th.

Disclosures: Bégué, Bumbasirevic, Fedeli and Mahaisavariya report no relevant financial disclosures.